NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A1777
SPONSOR: Lavine (MS) TITLE OF BILL:
An act to amend the public health law and the insurance law, in relation
to health care professional applications and terminations
PURPOSE OR GENERAL IDEA OF BILL:
To provide health care practitioners with due process protections in
order to allow and encourage a meaningful continuity of care to health
insurance enrollees.
SUMMARY OF PROVISIONS:
Section one amends section 4406-d of the Public Health Law to clarify
the due process protections afforded to a health care professional for'
contract terminations. This section also refines the process by which
members of a hearing panel are chosen to require that one member is
appointed by the insurer, one member is appointed by the subject of the
hearing and that the third panelist is chosen by the other two panel
members.
Section two amends section 4803 of the Insurance Law to clarify that the
due process protections afforded to a health care professional for
contract terminations. This section also refines the process by which
members of a hearing panel are chosen to require that one member is
appointed by the insurer, one member is appointed by the subject of the
hearing and that the third panelist is chosen by the other two panel
members.
Section three contains the effective date, which is immediate.
JUSTIFICATION:
The relationship between a patient and his or her physician is integral
to the effective, efficient provision of quality health care services.
The better a physician knows a patient, knows the patient's history, is
aware of the patient's level of participation in improving his or her
own health and can meld these factors with the scientific practice of
medicine, the more likely the patient will receive the best and most
efficient health care. As part of New York's Managed Care Bill of
Rights, the Legislature recognized the value gained by preserving the
patient's relationships with their provider by establishing meaningful
due process protections for all providers by prohibiting plans from
terminating a provider without out notice and without an opportunity to
be heard by a panel of clinical peers. However, in some instances insur-
ers have avoided triggering these important protections by waiting to•
drop physicians from their panels until the expiration of their partic-
ipating contract for reasons that may be related to these physicians
challenging the insurer's payment practices or the physician's referral
of patients to certain needed specialists. This bill would extend these
important statutory due process protections, currently applicable to
contract terminations, to contract non-renewals to assure that such
non-renewals occur for valid reasons.
PRIOR LEGISLATIVE HISTORY:
2004: A4000- Passed Assembly
2014: A6498- Passed Assembly
2017: A2704 Passed
2019-20: A2835 Ordered third reading/S3463 referred to Health
2021-2022 A4177 Ordered to third reading
FISCAL IMPLICATIONS FOR STATE AND LOCAL GOVERNMENTS:
To be determined
EFFECTIVE DATE:
Shall take effect immediately.
STATE OF NEW YORK
________________________________________________________________________
1777
2023-2024 Regular Sessions
IN ASSEMBLY
January 20, 2023
___________
Introduced by M. of A. LAVINE, COLTON, GLICK, SAYEGH, SEAWRIGHT, TAYLOR,
VANEL, STIRPE -- Multi-Sponsored by -- M. of A. HEVESI -- read once
and referred to the Committee on Health
AN ACT to amend the public health law and the insurance law, in relation
to health care professional applications and terminations
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Subdivisions 2, 3, 4, 5, 6, 7, 8 and 9 of section 4406-d of
2 the public health law, as added by chapter 705 of the laws of 1996, are
3 amended to read as follows:
4 2. (a) A health care plan shall not terminate or not renew a contract
5 with a health care professional unless the health care plan provides to
6 the health care professional a written explanation of the reasons for
7 the proposed contract termination and an opportunity for a review or
8 hearing as hereinafter provided. This section shall not apply in cases
9 involving imminent harm to patient care, a determination of fraud, or a
10 final disciplinary action by a state licensing board or other govern-
11 mental agency that impairs the health care professional's ability to
12 practice.
13 (b) The notice of the proposed contract termination or non-renewal
14 provided by the health care plan to the health care professional shall
15 include:
16 (i) the reasons for the proposed action;
17 (ii) notice that the health care professional has the right to request
18 a hearing or review, at the professional's discretion, before a panel
19 [appointed by the health care plan] comprised of no fewer than three
20 health care professionals licensed to practice in the state of New York;
21 (iii) a time limit of not less than thirty days within which a health
22 care professional may request a hearing; and
23 (iv) a time limit for a hearing date which must be held within thirty
24 days after the date of receipt of a request for a hearing.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD02414-01-3
A. 1777 2
1 (c) The hearing panel shall be comprised of three [persons appointed
2 by the health care plan] health care professionals licensed to practice
3 by the state of New York in the same profession as the subject of the
4 review, one of whom is appointed by the health care plan, one of whom is
5 appointed by the health care professional who is the subject of the
6 hearing. The remaining member of the panel shall be chosen by the other
7 two panel members. At least one person on such panel shall be a clinical
8 peer in the same discipline and the same or similar specialty as the
9 health care professional under review. The hearing panel may consist of
10 more than three persons, provided however that the number of clinical
11 peers on such panel shall constitute one-third or more of the total
12 membership of the panel and provided further that the ratio of the
13 number of health care professionals appointed by the health care plan to
14 the number of health care professionals appointed by the subject of the
15 hearing to the number of health care professionals chosen by the other
16 panel members remains one to one to one.
17 (d) The hearing panel shall render a decision on the proposed action
18 in a timely manner. Such decision shall include reinstatement of the
19 health care professional by the health care plan, provisional rein-
20 statement subject to conditions set forth by the health care plan or
21 termination of the health care professional. Such decision shall be
22 provided in writing to the health care professional.
23 (e) A decision by the hearing panel to terminate or not renew a health
24 care professional shall be effective not less than thirty days after the
25 receipt by the health care professional of the hearing panel's decision;
26 provided, however, that the provisions of paragraph (e) of subdivision
27 six of section [four thousand four] forty-four hundred three of this
28 article shall apply to such termination or non-renewal.
29 (f) In no event shall termination be effective earlier than sixty days
30 from the receipt of the notice of termination.
31 3. [Either party to a contract may exercise a right of non-renewal at
32 the expiration of the contract period set forth therein or, for a
33 contract without a specific expiration date, on each January first
34 occurring after the contract has been in effect for at least one year,
35 upon sixty days notice to the other party; provided, however, that any
36 non-renewal shall not constitute a termination for purposes of this
37 section.
38 4.] A health care plan shall develop and implement policies and proce-
39 dures to ensure that health care professionals are regularly informed of
40 information maintained by the health care plan to evaluate the perform-
41 ance or practice of the health care professional. The health care plan
42 shall consult with health care professionals in developing methodologies
43 to collect and analyze health care professional profiling data. Health
44 care plans shall provide any such information and profiling data and
45 analysis to health care professionals. Such information, data or analy-
46 sis shall be provided on a periodic basis appropriate to the nature and
47 amount of data and the volume and scope of services provided. Any
48 profiling data used to evaluate the performance or practice of a health
49 care professional shall be measured against stated criteria and an
50 appropriate group of health care professionals using similar treatment
51 modalities serving a comparable patient population. Upon presentation of
52 such information or data, each health care professional shall be given
53 the opportunity to discuss the unique nature of the health care profes-
54 sional's patient population which may have a bearing on the health care
55 professional's profile and to work cooperatively with the health care
56 plan to improve performance.
A. 1777 3
1 [5.] 4. No health care plan shall terminate a contract or employment,
2 or refuse to renew a contract, solely because a health care provider
3 has:
4 (a) advocated on behalf of an enrollee;
5 (b) filed a complaint against the health care plan;
6 (c) appealed a decision of the health care plan;
7 (d) provided information or filed a report pursuant to section forty-
8 four hundred six-c of this article; or
9 (e) requested a hearing or review pursuant to this section.
10 [6.] 5. Except as provided herein, no contract or agreement between a
11 health care plan and a health care professional shall contain any
12 provision which shall supersede or impair a health care professional's
13 right to notice of reasons for termination or non-renewal and the oppor-
14 tunity for a hearing or review concerning such termination or non-rene-
15 wal.
16 [7.] 6. Any contract provision in violation of this section shall be
17 deemed to be void and unenforceable.
18 [8.] 7. For purposes of this section, "health care plan" shall mean a
19 health maintenance organization licensed pursuant to article forty-three
20 of the insurance law or certified pursuant to this article or an inde-
21 pendent practice association certified or recognized pursuant to this
22 article.
23 [9.] 8. For purposes of this section, "health care professional" shall
24 mean a health care professional licensed, registered or certified pursu-
25 ant to title eight of the education law.
26 § 2. Subsections (b), (c), (d), (e), (f), (g) and (h) of section 4803
27 of the insurance law, as added by chapter 705 of the laws of 1996, are
28 amended to read as follows:
29 (b) (1) An insurer shall not terminate or not renew a contract with a
30 health care professional for participation in the in-network benefits
31 portion of the insurer's network for a managed care product unless the
32 insurer provides to the health care professional a written explanation
33 of the reasons for the proposed contract termination and an opportunity
34 for a review or hearing as hereinafter provided. This section shall not
35 apply in cases involving imminent harm to patient care, a determination
36 of fraud, or a final disciplinary action by a state licensing board or
37 other governmental agency that impairs the health care professional's
38 ability to practice.
39 (2) The notice of the proposed contract termination or non-renewal
40 provided by the insurer to the health care professional shall include:
41 (i) the reasons for the proposed action;
42 (ii) notice that the health care professional has the right to request
43 a hearing or review, at the professional's discretion, before a panel
44 [appointed by the insurer] comprised of no fewer than three health care
45 professionals licensed to practice by the state of New York;
46 (iii) a time limit of not less than thirty days within which a health
47 care professional may request a hearing or review; and
48 (iv) a time limit for a hearing date which must be held within not
49 less than thirty days after the date of receipt of a request for a hear-
50 ing.
51 (3) The hearing panel shall be comprised of three [persons appointed
52 by the insurer] health care professionals licensed to practice by the
53 state of New York in the same profession as the subject of the review,
54 one of whom is appointed by the insurer, one of whom is appointed by the
55 health care professional who is the subject of the hearing. The remain-
56 ing member of the panel shall be chosen by the other two panel members.
A. 1777 4
1 At least one person on such panel shall be a clinical peer in the same
2 discipline and the same or similar specialty as the health care profes-
3 sional under review. The hearing panel may consist of more than three
4 persons, provided however that the number of clinical peers on such
5 panel shall constitute one-third or more of the total membership of the
6 panel and provided further that the ratio of the number of health care
7 professionals appointed by the health care plan to the number of health
8 care professionals appointed by the subject of the hearing to the number
9 of health care professionals chosen by the two other panel members
10 remains one to one to one.
11 (4) The hearing panel shall render a decision on the proposed action
12 in a timely manner. Such decision shall include reinstatement of the
13 health care professional by the insurer, provisional reinstatement
14 subject to conditions set forth by the insurer or termination of the
15 health care professional. Such decision shall be provided in writing to
16 the health care professional.
17 (5) A decision by the hearing panel to terminate or not renew a health
18 care professional shall be effective not less than thirty days after the
19 receipt by the health care professional of the hearing panel's decision;
20 provided, however, that the provisions of subsection (e) of section four
21 thousand eight hundred four of this article shall apply to such termi-
22 nation.
23 (6) In no event shall termination or non-renewal be effective earlier
24 than sixty days from the receipt of the notice of termination or non-re-
25 newal.
26 (c) [Either party to a contract for participation in the in-network
27 benefits portion of an insurer's network for a managed care product may
28 exercise a right of non-renewal at the expiration of the contract period
29 set forth therein or, for a contract without a specific expiration date,
30 on each January first occurring after the contract has been in effect
31 for at least one year, upon sixty days notice to the other party;
32 provided, however, that any non-renewal shall not constitute a termi-
33 nation for purposes of this section.
34 (d)] An insurer shall develop and implement policies and procedures to
35 ensure that health care providers participating in [the] the in-network
36 benefits portion of an insurer's network for a managed care product are
37 regularly informed of information maintained by the insurer to evaluate
38 the performance or practice of the health care professional. The insurer
39 shall consult with health care professionals in developing methodologies
40 to collect and analyze provider profiling data. Insurers shall provide
41 any such information and profiling data and analysis to these health
42 care professionals. Such information, data or analysis shall be provided
43 on a periodic basis appropriate to the nature and amount of data and the
44 volume and scope of services provided. Any profiling data used to evalu-
45 ate the performance or practice of such a health care professional shall
46 be measured against stated criteria and an appropriate group of health
47 care professionals using similar treatment modalities serving a compara-
48 ble patient population. Upon presentation of such information or data,
49 each such health care professional shall be given the opportunity to
50 discuss the unique nature of the health care professional's patient
51 population which may have a bearing on the professional's profile and to
52 work cooperatively with the insurer to improve performance.
53 [(e)] (d) No insurer shall terminate or refuse to renew a contract for
54 participation in the in-network benefits portion of an insurer's network
55 for a managed care product solely because the health care professional
56 has (1) advocated on behalf of an insured; (2) has filed a complaint
A. 1777 5
1 against the insurer; (3) has appealed a decision of the insurer; (4)
2 provided information or filed a report pursuant to section forty-four
3 hundred six-c of the public health law; or (5) requested a hearing or
4 review pursuant to this section.
5 [(f)] (e) Except as provided herein, no contract or agreement between
6 an insurer and a health care professional for participation in the
7 in-network benefits portion of an insurer's network for a managed care
8 product shall contain any provision which shall supersede or impair a
9 health care professional's right to notice of reasons for termination or
10 non-renewal and the opportunity for a hearing concerning such termi-
11 nation or non-renewal.
12 [(g)] (f) Any contract provision in violation of this section shall be
13 deemed to be void and unenforceable.
14 [(h)] (g) For purposes of this section, "health care professional"
15 shall mean a health care professional licensed, registered or certified
16 pursuant to title eight of the education law.
17 § 3. This act shall take effect immediately.
